Mutual aid works, whether it’s 12 step, Lifering, SMART or WFS

photo credit: Jeff Tabaco

The Journal of Substance Abuse Treatment just published a study examining outcomes for 12 step groups and Lifering, Women for Sobriety (WFS), and SMART Recovery.

The researchers described their findings this way:

The present study contributes the first longitudinal, comparative data on 12-step groups and the largest secular, abstinence-based alternatives available in the U.S.: WFS, SMART, and LifeRing. Results revealed strong, robust associations between higher primary group involvement and all three outcomes across 6- and 12-month follow-ups, along with no significant interactions between primary group affiliation at baseline and 6-month primary group involvement in any model. These results tentatively suggest equivalent efficacy for WFS, LifeRing, and SMART, compared to 12-step groups. They suggest that mutual help group involvement—measured as meeting attendance; having a regular or home group; having a close friend or sponsor in the group; leading, convening, or facilitating meetings; and doing volunteer or service work—offers equivalent benefits in relation to substance use and problems regardless of group choice. Findings are noteworthy given the almost total lack of evidence on the efficacy of alternatives to the 12-step model in recovery from alcohol and drug abuse. Though findings should be confirmed in larger samples, they do support referral to a range of abstinence-focused alternatives to AA.

The study controlled for the differences in goals for the various groups. Vox posted a story about the study. They describe those findings this way:

The study, conducted by the Alcohol Research Group at the Public Health Institute in California and published last month in the Journal of Substance Abuse Treatment, surveyed more than 600 people with alcohol use disorder (AUD), who were divided by which mutual help group they primarily participated in. Researchers followed up at six months then 12 months, measuring involvement in the groups and various substance use outcomes, including abstinence from drinking and alcohol-related problems.

After controlling for several factors, the researchers concluded that “[Women for Sobriety], LifeRing, and SMART are as effective as 12-step groups for those with AUDs.”

“Essentially, that’s the story,” Zemore said. “We were really interested in whether the effects of involvement on recovery outcomes depended on which group [participants] were in. And we found that they did not.”

There were some differences in the data. People who reported SMART as their primary group seemed to have worse substance use outcomes, and there were lower odds of total abstinence among LifeRing members.

That might have something to do with differences in recovery goals. For example, AA really emphasizes total abstinence from drinking as the solution to alcohol addiction. Groups like SMART and LifeRing, meanwhile, can be friendlier to the idea of members moderating their drinking but not quitting altogether. That could affect substance use outcomes — and especially abstinence outcomes.

The study’s survey data suggests this is in fact what was going on: When researchers controlled for people’s recovery goals — meaning, whether they wanted to commit to lifetime total abstinence or not — the differences between the 12-step groups, SMART, and LifeRing went away.

“That suggests that people with less commitment to lifetime total abstinence are more likely to participate in SMART and LifeRing than they are to participate in 12-step groups,” Zemore said. “That’s why you’re seeing these associations between SMART and LifeRing affiliation at baseline and worse recovery outcomes when you control for involvement.” She added, “But I want to emphasize that these go away when you control for recovery goals.”

Building on existing research

Bill White has summarized research on various mechanisms of change in mutual aid groups (Look at page 128. It includes citations.):

• problem recognition and commitment to change;
• regular re-motivation to continue change efforts;
• counter-norms that buffer the effects of heavy drinking social networks and alcohol and other drug use promotion in the wider culture;
• sustained self-monitoring;
• increased spiritual orientation;
• enhanced coping skills, particularly the recognition of high-risk situations and stressors;
• increased self-efficacy;
• social support that offsets the influence of pro-drinking social networks;
• helping others with alcohol and other drug problems;
• exposure to sober role models and experience-based advice on how to stay sober;
• participation in rewarding sober activities;
• 24-hour accessibility of assistance; and
• potentially lifelong supports that do not require financial resources.

This study has also provided further affirmation of studies finding that, while mutual aid attendance may predict some improvement in outcomes, mutual aid involvement (having a sponsor, a home group, service activities, social contact with friends in the group, etc.) is a much more potent predictor.

See also:

• The evidence-base for 12 step recovery
• Strong evidence
• How AA and NA work
• How AA and NA work, part 2

UPDATE:

Jeff Jay raises an important point in the comments below:

Having different goals (abstinence vs maybe abstinent) is what makes these groups’ outcomes “equivalent.” Which goes to show that if we control for the right factors, we can also make apples and oranges equivalent.

12-step members were more likely to be abstinent at follow-up.

If I understand correctly, as a secondary aim, the study controlled for the differences in goals by measuring whether the members achieved their goal. (Which may, or may not, be in the long term interests of themselves and their loved ones.)

The present study contributes the first longitudinal, comparative data on 12-step groups and the largest secular, abstinence-based alternatives available in the U.S.: WFS, SMART, and LifeRing. Results revealed strong, robust associations between higher primary group involvement and all three outcomes across 6- and 12-month follow-ups, along with no significant interactions between primary group affiliation at baseline and 6-month primary group involvement in any model. These results tentatively suggest equivalent efficacy for WFS, LifeRing, and SMART, compared to 12-step groups. They suggest that mutual help group involvement—measured as meeting attendance; having a regular or home group; having a close friend or sponsor in the group; leading, convening, or facilitating meetings; and doing volunteer or service work—offers equivalent benefits in relation to substance use and problems regardless of group choice.

As for their goals, the study reports on recovery goals this way:

our baseline PAL data suggested that LifeRing and SMART members have less stringent alcohol recovery goals than 12-step members: While large majorities of 12-step (72%) and WFS (67%) members endorsed a recovery goal of lifetime total abstinence, endorsement rates for this same goal were significantly lower among LifeRing members (58%) and lowest of all among SMART members (40%) (Zemore et al., 2017).

Interesting that 28% of 12-step members did not endorse a goal of lifetime abstinence. (I suppose these are new initiates who may not be totally sold on 12-step’s emphasis abstinence?)